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  • 1. Surgical Bleeding Presented by Nargess Tavakoli Guilan University of Medical Sciences
  • 2. Excessive Intraoperative or Postoperative Bleeding
  • 3. may be the result of:
    • ineffective local hemostasis
    • complications of blood transfusion
    • a previously undetected hemostatic defect
    • consumptive coagulopathy, and/or fibrinolysis.
  • 4.  
  • 5. Ineffective Local Hemostasis Ineffective Local Hemostasis
  • 6.
    • Excessive bleeding from the field of the procedure
    • without bleeding from other sites
    • e.g. cvp line
    • intravenous line
    • tracheostomy
  • 7. exception
    • operations on the
    • Prostate
    • Pancreas
    • Liver
  • 8.
    • operative trauma =>
    • local plasminogen activation =>
    • increased fibrinolysis on the raw surface
  • 9.
    • EACA: 24-48-hour interruption of plasminogen activation
  • 10.
    • laboratory investigation must be confirmatory
    • number of plt
    • actual plt count: if the smear is equivocal
    • aPTT
    • PT
    • TT
  • 11. complications of blood transfusion
  • 12.  
  • 13. complications of blood transfusion
    • thrombocytopenia due to massive blood transfusion
    • hemolytic transfusion reaction
    • Transfusion purpura
  • 14. thrombocytopenia due to massive blood transfusion
  • 15.
    • massive transfusion
    • a single transfusion greater than 2500 mL
    • 5000 mL transfused over a period of 24 hours.
  • 16. thrombocytopenia due to massive blood transfusion
    • usually not associated with hemostatic failure
  • 17.
    • prophylactic administration of plt: not indicated
  • 18. if evidence of diffuse bleeding:
    • empiric transfusion of 8_10 packs of fresh platelet concentrates
    • no clear association between plt count,BT & the occurrence of profuse bleeding
  • 19. hemolytic transfusion reaction
  • 20.
    • Example:
    • anesthetized patient :
    • diffuse bleeding in an operative field that had previously been dry
  • 21.
    • Pathogenesis:
    • red blood cells lysis=>
    • release of ADP=>
    • diffuse plt aggregation=>
    • the plt clumps are swept out of the circulation
  • 22.
    • Release of procoagulants =>
    • progression of the clotting mechanism =>
    • intravascular defibrination
    • The fibrinolytic mechanism may be triggered.
  • 23. Transfusion purpura
  • 24. Transfusion purpura
    • uncommon
  • 25.
    • donor plt :uncommon Pl A 1 group
    • Recipient makes Ab to the foreign plt Ag
    • foreign plt antigen attach to the recipient's own plt
  • 26.
    • sufficient titer of Ab to destroy recipent’s plt: within 6 or 7 days
    • resultant thrombocytopenia & bleeding may continue for several weeks
  • 27.
    • bleeding follows transfusion by 5 or 6 days:
    • Transfusion purpura as DDx.
  • 28. Management:
    • Platelet transfusions :
    • little help
    • damage from the Ab
    • Corticosteroids:
    • some help
    • self-limited
  • 29. DIC and disseminated fibrinolysis
  • 30. DIC and disseminated fibrinolysis
    • control mechanisms fail to restrain the hemostatic process to the area of tissue damage
  • 31. Caused by:
    • trauma
    • incompatible transfused blood
    • Sepsis
    • necrotic tissue
    • fat emboli
    • retained products of conception
    • toxemia of pregnancy
    • large aneurysms
    • liver diseases
  • 32.
    • distinguish between the two processes or the dominant element : important
  • 33.
    • No single test
    • can confirm or exclude the diagnosis or distinguish between the two disorders
  • 34. strong indications for DIC
    • The combination of
    • Thrombocytopenia
    • plasma protamine test for fibrin monomers:+
    • fibrinogen level : LOW
    • FDP : ELEVATED
  • 35.
    • The euglobulin lysis time
    • detects diffusefibrinolysis
  • 36. Biliary tract surgery in cirrhotic patients & Bleeding
    • Related to:
    • portal hypertension
    • coagulopathy associated with chronic liver disease
  • 37.
    • The tests used to distinguish DIC from fibrinolysis pertain
  • 38.
    • The therapeutic approach
    • IV vasopressin : temporary reduction in portal hypertension
    • EACA to correct the increased fibrinolysis
  • 39. The therapeutic approach
    • IV vasopressin : temporary reduction in portal hypertension
    • EACA to correct the increased fibrinolysis.
  • 40. Intra/Postoperative Bleeding & sepsis
    • Endotoxin-induced thrombocytopenia
    • Defibrination
  • 41. Endotoxin-induced thrombocytopenia
    • Gram Neg. sepsis
    • a labile factor (possibly factor V)
  • 42. Defibrination
    • meningococcemia
    • Clostridium perfringens sepsis
    • staphylococcal sepsis
    • Hemolysis leading to defibrination
    • Evaluation:plt count, INR, aPTT,TT
  • 43. Preoperative Evaluation of Hemostasis
  • 44. Ask the patient 8Qs
  • 45.
    • prolonged bleeding or swelling after biting the lip or tongue?
  • 46.
    • bruises without apparent injury?
  • 47.
    • prolonged bleeding after dental extraction?
  • 48.
    • excessive menstrual bleeding?
  • 49.
    • bleeding problems associated with major and minor operations?
  • 50.
    • medical problems receiving a physician's attention within the past 5 years?
  • 51.
    • medical problems receiving a physician's attention within the past 5 years?
  • 52.
    • medications including aspirin or remedies for headache taken within the past 10 days ?
  • 53.
    • a relative with a bleeding problem?
  • 54. Four levels
    • Based on:
    • History
    • surgical procedure
  • 55. level I
    • History: negative
    • procedure: relatively minor
    • e.g., breast biopsy
    • hernia repair
    • no screening tests are recommended
  • 56. level II
    • history:negative
    • major operation but usually is not attended by significant bleeding
    • platelet count
    • PBS
    • PTT
  • 57. Level III
    • history : suggestive of defective hemostasis
    • procedure :hemostasis may be impaired, e.g., operating using pump oxygenation or cell savers
    • procedures : a large, raw surface is anticipated
    • situations :minimal postoperative bleeding could be injurious(intracranial operations)
  • 58. Level III
    • plt count & bleeding time test : platelet function;
    • aPTT & INR : coagulation
    • the fibrin clot should be incubated to screen for abnormal fibrinolysis
  • 59. Level IV
    • history highly suggestive of a hemostatic defect
    • consult with ahematologist
    • tests prescribed for level III
    • BT test :4 hours after ingestion of 600 mg of aspirin operation is scheduled to take place 10 or more days after this study.
  • 60. Level IV
    • emergency procedure:
    • platelet aggregation tests ADP, collagen, epinephrine, and ristocetin
    • TT : detect any dysfibrinogenemia or a circulating, weak, heparin-like anticoagulant.
  • 61.
    • uremic patients
    • Qualitative platelet abnormality
    • most common deficit
    • best detected by the bleeding time test .
  • 62. Thanks for your attention